What is the procedure to complete a Do Not Resuscitate (DNR) request?

Procedure for Completing a DNR Request

To complete a Do Not Resuscitate (DNR) request, the attending physician must document the order in writing in the patient's chart according to local policy, including a detailed note explaining the rationale, specific limitations of care, and documentation of discussions with the patient, surrogate, and family. 1

Step-by-Step DNR Request Process

1. Initial Discussion with Patient/Surrogate

• Physicians should initiate discussions about CPR with all patients admitted for medical and surgical care or with their surrogates 1
• Be frank with the patient about the probability of surviving in-hospital cardiac arrest, as most older patients understand prognostic information and can make informed decisions 1
• Reassure the patient and family that pain control and symptom management will continue even if resuscitation is withheld 1

2. Documentation Requirements

• The DNR order must be written (oral DNR orders are not acceptable) 1
• The order must include:
  • Explicit instructions for specific emergency interventions that may arise
  • Clear specification of which interventions are to be withheld
  • Documentation of discussions with patient/surrogate/family
  • Rationale for the DNR order 1, 2

3. Scope Specification

• DNR orders should preferably state either full resuscitation or no attempt at resuscitation 1
• The order should specify which interventions are permitted and which are to be withheld 2
• Be explicit about whether the order includes:
  • Chest compressions
  • Defibrillation
  • Intubation
  • Mechanical ventilation
  • Administration of vasopressors
  • Use of blood products
  • Administration of antibiotics 1, 2

4. Format and Location

• The DNR order must be documented in the patient's chart according to local policy 1
• Many institutions use standardized forms or electronic ordering systems 3
• Some facilities implement resuscitation status armbands to improve communication of DNR status 3

Important Considerations

Clarifying Scope of DNR

• A DNR order does not automatically preclude other forms of treatment 1
• All other appropriate care should be administered without delay 1
• DNR orders carry no implications about treatments such as:
  • Parenteral fluids
  • Nutrition
  • Oxygen
  • Analgesia
  • Sedation
  • Antiarrhythmics
  • Vasopressors (unless specifically included in the order) 1, 2

Periodic Review

• DNR orders should be reviewed periodically as per local protocol 1
• Review is particularly important if the patient's condition changes 1, 2
• DNR orders should be reviewed before surgery by the anesthesiologist, attending surgeon, and patient/surrogate 1

Common Pitfalls to Avoid

• Assuming DNR means withholding all treatments (DNR only applies to specific interventions listed in the order) 2
• Failing to specify which interventions are permitted, leading to confusion among healthcare providers 2
• Not documenting discussions thoroughly, which may lead to misunderstandings about patient wishes 2
• Not reviewing DNR status when the patient's condition changes 2

By following this structured approach to DNR documentation, healthcare providers can ensure that patients' wishes regarding resuscitation are respected while maintaining appropriate medical care for all other aspects of treatment.